What Is The Missing Tooth Clause?

Updated: Jul 17

Have you ever heard about it and should you know about it? If you don't, you may want to be aware of it going forward.


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Table of Contents


What is a missing tooth clause?

Under a dental insurance plan, if there is a missing tooth clause, it would mean that you would have no coverage in replacing the tooth if you were already missing the tooth before you signed up for the insurance. Put another way, there will be zero insurance benefit if you decide to replace that missing tooth.


This clause is the medical insurance equivalent of having a pre-existing condition. If you already had said medical condition before you bought the medical insurance, all treatments related to that condition would be a non-covered benefit.


In the medical world and also in dentistry, what this means is that you would have to pay for all of the procedures related to that missing tooth as 100% out of pocket. That could create financial challenges because you were probably expecting your dental insurance to help out since that was the reason you bought it right?



Why is this important to you?

It is important to be aware of the presence of this clause in your dental insurance contract in case you are someone with a missing tooth.


According to studies, the prevalence of tooth loss for adults between 20-64 years old was about 35.7%.


It gets worse if you look at the population over 65 by the CDC:

  • 26% have 8 or fewer teeth

  • 17% have lost all of their teeth

  • Adults who are poor, have less than a high school education, and are cigarette smokers are 3x more likely to lose all of their teeth.

As you can see, it is quite common to be missing teeth, hopefully you're not missing one right now but if you are, you should read the insurance contract fine print carefully. You don't want to end up choosing an insurance plan that has the missing tooth clause. You would be paying money for an insurance that does not cover teeth replacement.


Missing teeth replacement treatments include:

If you were unaware that you had such a clause, you could be stuck with a very large bill from your dentist. The dental office will usually file the claim on your behalf but if your plan has this clause, the claim will come back denied. You can try appealing a denied claim but they will read you the fine print that explains the denial was due to a pre-existing condition.



How can you avoid this situation if you were unaware?

You can avoid having to be stuck with a large dental bill by having your dentist submit a predetermination prior to beginning any dental treatment. A predetermination is usually recommend for any major dental procedure. Major work is defined as:

  • Dental crowns, tooth caps

  • Dental bridges

  • Dental Implants

  • Complete dentures are also included

There is absolutely no reason not to submit a pre-approval. It is only to your benefit. The only downside is that it usually takes about 2 weeks to hear back from your insurance regarding their decision to cover the procedure or not.



How do I check if I have this pre-existing condition clause?

There are two ways to find out if you have this fine print in your insurance plan:

  1. Call the insurance company and ask

  2. Ask your human resource (HR) department

The first one is self explanatory but the second one, most people miss. Why would your HR know? That is simple, your HR actually helped your company negotiate for the insurance benefits so they would know if it was included or not. They should've been the one to help guide you in choosing the right insurance for your needs.



Take away:

Now that you know, please ask a lot of questions before you just sign up for a dental insurance. Make sure that it has coverage for the procedures that you will need. The missing tooth clause gets a lot of people! Basically if you were missing a tooth before your insurance is active, you will have no coverage for any of the replacement procedures!


Do you know what is another one, which gets people? Your dental insurance has orthodontic coverage but only for those age 19 and under!

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About the author: Dr David Chen, DDS

Hello, I'm Dr Chen and I'm an actively practicing dentist in Long Island City, NY. I graduated from Columbia University College of Dental Medicine in 2016 but prior to going to dental school I was already working in the dental field. It's been more than a decade since I first got to know dentistry and let me tell you, time flies by quickly. Since then I've developed a fondness for writing, which is how this all got started!

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Medical Disclaimer:

This blog is purely meant for information purposes and should not be used as medical advice. Each situation in your mouth is unique and complex. It is not possible to give advice nor diagnose any oral conditions based on text nor virtual consultations. The best thing to do is to go in person to see your dentist for an examination and consultation so that you can receive the best care possible.

The purpose of all of this oral health information is to encourage you to see your dentist and to inform you of what you may expect during your visit. Due to the unfortunate nature of dentistry, there isn't really any true home remedies that will get rid of dental problems. Roughly 99.99% of them require in-person intervention by a healthcare professional.

Hint: That is the reason why you can't eliminate seeing dentists in your life!